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2008 Lecture transcript

Regional Dentistry: equity in training and treatment

Latrobe University is just 40 years old, and is engaging in a major review of its activities, and redefining its approach to education. The act which enabled the creation of the University defined the values on which the University should operate. These included access to education for students for whom a traditional University education would be impossible; developing the student not only for the particular field of study, but for participation in the community and in life, and the research aim of the new University was to provide research to benefit the whole community. The new vice-chancellor, Paul Johnson, has stated his wish that Latrobe again becomes a radical university.

The creation of first the department of Oral Health and then the School of Dentistry and Oral Health is made with radical intention, confronting the metro centric view of dental education, which has held sway in Australia for the last century. Ours will be a radical school, designed to address chronic problems and entrenched attitudes, with teaching in a rural and regional setting. La Trobe University has made a major expansion of its Health Science programs with the introduction of firstly Oral Health in 2007 and then Dentistry in 2009. This expansion was created to address a worsening rural workforce shortage. The fundamental objective is to improve the oral health of rural and regional people in Victoria.

What is the argument for this major development? I will firstly consider the evidence for the oral health status of rural compared to metro Victorians, then discuss the workforce issues which surround the provision of dental services, and some of the tensions and differences between public and private practice. Discussion of the proposed course for training dental staff will follow and finally I will present our intentions to monitor and review the changes which ensue from the creation of this program, together with possible collaborations.

What is the social backdrop in rural and regional Australia within which dentistry and oral health must work?

Mark Gussy, just appointed to La Trobe as the first Associate Professor in Oral Health in Australia, (2008) has written:

"The social patterns (in rural areas) in recent years include declining agricultural income and activity, high levels of migration of young adults to metropolitan areas and a redistribution or withdrawal (on economic grounds) of many essential public services including healthcare. In addition, residents of rural towns are significantly more likely to receive a government welfare payment as their primary source of income when compared to those living in major urban areas."

What are the consequences of this situation?

Felix Pintado, the recently appointed chief executive officer of Dental Health Services Victoria, has presented the following information in 2006:

There are major health differences between regional and rural Victoria and metropolitan Victoria in many diseases

Marginally lower life expectancy at birth.

Lower standards of health overall and continued poor health status of indigenous Australians.

Advances in technologies results in centralisation of services, making cost and accessibility significant issues.

Funding models developed for Metro do not adequately account for the realities of rural costs.

The knowledge of the oral health disadvantage in rural and regional Victoria is limited. This reflects the lack of investigation in this area. However, the indications are that rural and regional Victorians have significantly higher levels of dental disease and disadvantage than metropolitan Melbourne. Gussy (2008) reported that

"Access to dental services is an example of the disadvantage experienced in these communities. Dentists tend to cluster in cities with relatively fewer practising in rural areas. In Victoria, the capital city Melbourne has a dentist: population ratio of 52.4 per 100,000 compared with 29.9 in all other areas. The model of dental service delivery in Australia is similar to that in the United States where the majority of dental practitioners are general dentists who work independently in the private sector."

So, we have an unholy trinity of social disadvantage, health disadvantage and oral health disadvantage. What are the practicalities of addressing this issue?

The practice of conventional dentistry requires considerable infrastructure, which in turn requires significant funding and commitment to ongoing funding. With a visionary commitment in 2006, Professor Hal Swerissen and others convinced the Victorian State government to agree to the significant capital funding needed for a major expansion of dental education and the provision of dental services to the citizens of Victoria.

Dental chairs, the instruments, the backup to provide safe working places such as infection control and sterilisation are all required to provide dental treatment to modern standards. These issues mean that dentistry is not easily transportable, although of course, there are the famous school dental caravans that trip around the countryside at a very irregular pace, pulled by a rather tired donkey. So, dentistry is capital intensive for treatment, and the treatment for public patients particularly requires significant investment from the public purse. There has been remarkable progress in this area, with a large number of public dental clinics opening, with clinics and chairs across the state. There has been a major commitment of public funds to support the La Trobe dental school initiative. The initial dental therapy hygiene/program in the Department of Oral Health received significant funding to refurbish the 6th floor of the Anne Caudle Centre in Bendigo for a teaching clinic, and between 10 and 12 chairs are available for teaching. It is hoped that there will be outplacements at Echuca, Maryborough and possibly other surrounding clinics. When the dental initiative was announced, the state government committed funding for additional places in Mildura – 8 total chairs, 6 student chairs, Wodonga – 10 total chairs, 6 student chairs, and Melton – 10-12 total chairs, 9 or 10 student chairs. There will therefore be 21 chairs for student teaching. I calculate 47 chairs or so will be needed, and the recent Australian Dental Council has advised that they recommend 55 chairs.

These clinics are just the start. There are also requests pending for funding for a specialty teaching clinic in Bendigo and further capacity for development perhaps in Ballarat and Swan Hill, and elsewhere. It is essential that the capital programme continues to allow a high-quality educational program to develop. This will be a major challenge for the School, University and funding agencies.

There are currently discussions about how many experienced clinical staff, and how many students should be present in the clinics. Defining and refining these issues will be a challenge for the community health Centre hosts and La Trobe University. The concept of a clinic, which provides useful service and which exists mainly for educational reasons, is largely unknown in dentistry in Australia. This remarkable expansion of facilities creates a large demand for professional staff, both academic and clinical, and there is significant competition for such staff. However, a little more background to dentistry, and how it is arranged in Australia.

The private sector provides the largest volume of dental services, with 80% or so of dentists in private practice.

There is a major cultural difference between private and public sectors.

Public sector

Private sector

Eligibility

Health Care card, Pension card

Funds

Income system

Salaried

Fee per item of service

Relationship with the patient

Generic — "the clinic's patient"

Personal — "my patient"

Discretion about accepting patients

None, if eligible

Absolute

Clinical freedom

Low, set by funding agencies

Variable, set by patient resources

Control over direction of the operation/facility

Limited

Potent

Income

Modest

Good to high

Business responsibilities

Low, but growing

High, but growing

Proportion of dentists

15%

80%

So, we train dental and oral health students behind the iron curtain and then they practice in the west.

The solution to the rural and regional dental workforce shortage must be one that gives experience, or at least knowledge, of the system in which four out of five graduates will work.

The La Trobe teaching clinics, spread over four or five small to medium-size clinics across Victoria, must be places where students enjoy dentistry, and where they can undertake a full range of treatments, with appropriate professional supervision. Many public clinics, outside of the Royal dental Hospital of Melbourne, do not receive funding to undertake treatments other than the most simple. One of the broad aims of the La Trobe initiative is to spread the provision of more complex items of treatment to patients outside of Metro Melbourne. The distribution of service to eligible public patients is clearly grossly inequitable, with some services such as fixed orthodontics and implant therapy being almost exclusively provided in metropolitan Melbourne.

The differences in treatment between public and private sectors can be seen in my speciality area, that of Prosthodontics, where teeth are repaired and replaced. A common treatment for badly damaged teeth is to place a crown, or "cap" onto a prepared tooth. Stanceiwicz and Wilson surveyed nearly all of the dental laboratories in Melbourne in 1997, and projected that at least 20, 000 crowns would be made in Melbourne in a calendar year. This roughly equates to 7 crowns per 1000 patients per year in the private sector.

In 2007, the public system provided 759 crowns for around 1.5 million eligible patients, or about 0.5 crowns per 1000 patients. You would be fifteen times more likely to receive a crown if you were a private patient than if you were a public patient.

The private treatment undoubtedly includes elective treatment, but in my private prosthodontic practice in Sunbury, less than 10% of treatment is provided for "aesthetic" reasons. Not all private dentistry is a makeover for the vain.

It is unlikely that the public system will, or perhaps should, provide generous amounts of complex treatment, when resources are limited, and there are basic health needs to be met.

Rationing systems for treatment are in place: Orthodontics already treats only the most severe of malocclusions, and the provision of dental implants is under a closely monitored cap.

La Trobe is involved in the creation of public policy in this area: I have provided a draft document to DHSV for treatment priorities in tooth replacement – put simply, enough front teeth for dignity and enough back teeth for chewing, with priority for those who can maintain a health mouth. Associate Professor Mark Gussy is appointed to the DHSV clinical leadership council, and will be instrumental in the development of clinical policy.

One part of the La Trobe solution will be to encourage visiting specialists to undertake consultations, treatment and teaching in the peripheral clinics. In these consultation clinics, are the beginnings of provision of specialty treatment by specialists to rural and regional Victorians, which starts to address the difficult barriers placed by rural location. We need support from Government for assistance with transport and accommodation for these staff, and a commitment to ongoing funding for the clinical services, modest in scope as they may be.

We have already received a very generous welcome from the professional groups in Bendigo and Wodonga and we look forward to developing such ties in other clinics. It is planned that local general practitioners will visit the teaching clinics on a sessional basis and provide teaching for the students. We hope that local dentists will be happy to act as mentors and hosts for student visits during the students stay in the clinics. We will be seeking to appoint dentists at each clinic to fractional appointments, for general academic organisation and mentorship. Visiting academics, either by virtual or physical link, will continue teaching the students. The President of the Australian Dental Association Victorian Branch has already invited the students to become members of the ADA, and I received a very cordial welcome when I recently addressed the ADAVB council.

The School of Dentistry and Oral health is committed to engaging with the wider University, and we have already had preliminary discussions with Professor LEGGAT from the School of Public Health at La Trobe University about the construction of a business management course for final year dental students, probably with online presentation. The national picture for dental education is thriving, with dental schools starting intake, in Victoria with La Trobe at Bendigo 2008, in NSW with Charles Sturt University 2009 and northern Queensland with James Cook University, also 2009.

How will La Trobe University construct the dental course to be relevant to rural and regional Victoria?

The broad plan which has been supported by the State government with the creation of the teaching clinics is to develop a course where clinical exposure and activity is gained in a rural and regional setting.

The School borrows from many of the existing education facilities at La Trobe in Bendigo, such as lecture theatres and the library and student support activities. A sophisticated simulation laboratory has been added where students can practice the art and craft of dentistry and therapy/hygiene. The current facility has 31 chairs but will be expanded to be 61 simulation chairs and 30 technical practice chairs. All chairs will have access to audio-visual teaching, with student controlled and lecture controlled material. This expansion was funded by the State government with a grant of $1.5 million and significant Faculty support.

We hope to create a demonstration surgery, where clinical procedures can be performed, and issues of infection control can be taught.

The details of the curriculum are currently being developed, and the first and second years have recently been presented to the Australian dental Council for review. There will be a major public health stream throughout the course, in keeping with the rural and regional setting. The La Trobe course is in essence, simple: practical clinical skills are taught early, as part of a course which is designed specifically for oral health and dentistry. For example, we are creating a three semester series of units in medicine for dentistry, which is being controlled by the School of dentistry and oral health, rather than by an associated medical school.

Initial clinical experience will be gained by dental students and therapy hygiene students in Bendigo at the Anne Caudle Centre, and in the second half of 3rd year some students will be allocated to the distant clinics for initial clinical training. I have already advised the students to stay light on their feet, and carry a kitbag and a laptop for the last three years. There will be issues for mature students with families.

The distribution of the students creates some interesting issues for educational delivery. In some cases the lectures will go to the students, either directly via transport or indirectly via AV links. Sometimes the students will come to the centre. We imagine there will be occasions where the students will travel back to Bendigo for whole year teaching.

The details of the course are not yet settled, but you may expect some radical departures from the accepted norms. We will build on existing strengths at la Trobe University -- I have had initial discussions with the head of visual arts in Bendigo as to whether an oil painting course can be created for students rotating through Bendigo. The appreciation of colour, shape and the artistry needed are all essential for the practice of dentistry, and an appreciation of art is a skill to be used elsewhere in life.

The School has committed a grant from COLGATE to initiate an art competition amongst La Trobe visual arts students, past and present, for art works for the School facility in Bendigo. We hope to be able to support such works in the regional clinics too.

Our Students will not only provide dentistry to rural and regional citizens, but will provide a workforce for health education and promotion, in oral health, and in general health. We estimate that around 15 effective full-time educators will be dispersed across the state. This should have a major impact in improving the oral and general health of Victorians. Students will not only be trained as technicians and clinicians, but also as health educators as befits the radical traditions of La Trobe University.

So, I have outlined some of the issues of providing education in dentistry. How are we going to select students for this new course? How will we provide equity in training? How will we make sure that they stay the course? How will we encourage them to practice in rural and regional areas, where they are most needed? We start from the premise that rural and regional students trained rurally and regionally will end up practising rurally and regionally. We already know from many disciplines in Health Sciences that rural training and experience leads to increased rural practice. What are our selection procedures?

We accept students from several different sources. The major source of our firstyear intake in dentistry this year was school leavers and these students apply through the Victorian Tertiary Admissions Centre. There was exceptional competition this year for places in dentistry, and on first-round offers, the enter score required was 98.6. This was the highest score required for any course at La Trobe with a very high proportion of Metro applicants. There was an attempt to support regional students with a regional bonus of three enter points for applicants applying from a regional postcode. This proved to be almost completely ineffective. However, there was a high dropout rate of first-round applicants, and some regional students were made offers. The second source of students was mature age students with additional qualifications or experience. About half of the students that came from this path were rural students. Lastly, we offered places for lateral transfers for students already at Latrobe University, and again we were successful in attracting regional students. Eventually, out of 49 places confirmed in dentistry in 2008, 22 were rural and 27 were metro. Of the 27 places offered in the bachelor of oral health science program, the majority of students were rural.

The faculty of health sciences undertook analysis of the data to determine the appropriate level of regional bonus. It was determined that between five and 10 additional enter points, would allow us to select on first-round more than 50% of regional students.

We have acted on this for 2009 with a minimum regional bonus of five, rising to 10 for distant rural.

The faculty of health sciences is commencing a common first-year for nearly all of its health science programs. This will be offered both at Bundoora and across the state with the same syllabus and teaching concepts. The schools such as physiotherapy will accept students, who will undertake the common first-year and then proceed into physiotherapy. Other students may use the common first-year to undertake the bachelor of health science degree. The entry requirements for this degree are significantly lower than for the very competitive courses such as dentistry and physiotherapy. It is the intention of the school of dentistry and oral health to allow lateral transfers from high performing students, no matter what their enter score was on arriving at Latrobe, to gain entry to the dental course. It would then be possible to undertake a six-year course, finishing with a dental degree. I do not see this as an easy option.

The State government is keen to encourage dental and oral health students to complete their courses and to practice within the public sector after graduation. There is already a scholarship program running for the oral health students, and from 2000, there will be a very generous scheme funded to a third of a million dollars in 2010 and then two thirds of a million dollars recurring from 2011 for dental students. It is yet to be determined how this money will be allocated to individual students, but this is my hope that these funds will be used to support students who would otherwise find it very difficult to complete a fiveyear or six-year course.

How do we compare to the established dental school in Victoria, at the University of Melbourne? The newly named School of Dentistry will be a graduate School with entry following an appropriate bachelor degree. The minimum time required to complete this metro-centric course will be seven years. There is a significant proportion of International students. La Trobe accepts only Commonwealth Supported Places.

The future looks bright for La Trobe.

The final part of the presentation will be on how will we measure what we have done? Will we have achieved anything?

The school dentistry and oral health at Latrobe, has rapidly engaged in research proposals with the public dental services provider, Dental Health Services Victoria.

La Trobe University, the University of Melbourne, Monash University, and DHSV have joined together to prepare a grant application for a clinical centre of research excellence (CCRE). The proposal centres on developing a group of researchers, who can conduct research on behalf of dental health services Victoria. Latrobe University will lead two of the three groups and will make a major contribution to this application. If successful, the grant will provide 2 1/2 million dollars over five years.

The first theme of the CCRE is to integrate the database for dental services with larger databases. This theme will be led by Professor Liz Waters from the University of Melbourne, surprisingly not from the school of dentistry. There is an excellent database of dental treatment, held by DHSV, and Latrobe University has excellent access to this material.

The second theme is health services research. I am the leader of this theme representing the school of dentistry and oral health at Latrobe University, and it will be my function to ensure that the real experts in this team can have access to the resources of the CCRE.

The most essential part of any research project is the quality of the people involved. I will introduce the La Trobe staff involved and then the projects to you.

The project is led overall by Adjunct Professor Hanny Calache, who is the Clinical Director of DHSV, and who has a long and distinguished history in dental education and especially the teaching of dental auxiliaries. He has pulled together an impressive team from three universities with remarkable diplomatic skill, and will provide ongoing leadership across the research themes.

I would like to introduce an old friend, Adjunct Associate Professor Werner Bischof.

Werner is a specialist periodontist, with a practice in Geelong, and was part of the start up team for the Oral health course, and has continuing input into the dental course.

Werner is a Chief Investigator in the clinical Research theme, and he intends to develop a computer based periodontal risk assessment tool to reliably assess the periodontal or gum health of teeth. Secondly, he seeks to investigate the clinical decisions underpinning tooth loss and extraction, with the underlying basis being the profound effect tooth loss can have on people.

Deborah Cole, then Director of the Royal Dental Hospital of Melbourne, commented in 1998 that

"It horrifies me that many people, especially decision makers, have no realisation of the dental consequences for the financially disadvantaged. These people with their broken down mouths have their job prospects diminished, are more likely to have problems dealing with landlords, bank managers, the police, doctors, … The value judgements that all of these people make on a daily basis … come into effect to help these people stay in the poverty trap."

La Trobe University needs to have a social mission to right these wrongs. We are positioned to have a major impact and we aim to measure that impact with the second theme which La Trobe leads.

The Health Services research theme uses the skills of three outstanding La Trobe staff members:

Firstly, Associate Professor Mark Gussy brings very recent experience of research into the provision of dental services to young children, and has a growing international reputation in the field of cultural competence.

Secondly, Professor Sandy Leggat, Head of the School of Public Health, brings a wealth of international experience in health services management and workforce development.

Thirdly, Associate Professor Pauline Stanton from the Graduate School of Management will contribute in the areas of performance management, health workforce development and organisation strategies. One of the pleasures of academic life is work with people who where once your teachers. Pauline ran the Graduate Diploma in Health Administration which I undertook in the mid 90s, and she recalled my appearance at her door once, in full motorcycle leathers, apparently blocking out most of the daylight.

Lastly, I will be available to open fetes and kiss babies.

This formidable team will investigate two issues:

The impact of rural dental schools on oral health in regional Victoria

An Integrated Health care model - oral and allied health.

The real impact of this research will be the closure of the feedback loop between research and education.

Not content with this large grant application launched 5 months after the School was formed, a further adventure is planned.

In keeping with the activist approach of the Faculty of Health Sciences in Bendigo, an application has been made to the Federal Government for a Rural Health Support, Education and Training (RHSET) Program.

The aim will be to develop an educational package for health care workers on the oral health issues for mental health patients. The effects of therapeutic medications and the imperfect self care often present, only serve to worsen oral health and exacerbate the social problems described previously.

This project will be managed by Associate Professor Mandy Kenny, Director of Health Sciences on the Bendigo campus, who has a dynamic history of research into nursing workforce issues. Mark Gussy and I will also take part, with the major dental role being undertaken by Dr Ben Keith, recently appointed Senior lecturer. Ben brings a background of successful commercial practice and a keen interest and Masters Degree in public health to this important project.

Much of the material presented today is necessarily sketchy, but this project is real – we will produce eighty oral health workers a year from 2012, and they will have received a unique and radical La Trobe education, ready to go forth and spread light where there is darkness and heal the sick. As I frequently say to my dear colleague at the Royal Dental Hospital, Dr Basil Ian Steele, "Onwards, upwards, the state’s dental health".

To finish, I would like to pay tribute to the first Head of Department of Oral Health, Professor Marc Tennant from Western Australia, who with his energy and commitment, was instrumental in the creation of the Oral Health programme and laid the foundations for the Dental course.

What lies ahead for the first intake of dental students? It must have taken considerable courage to gamble your educational careers on an unknown unaccredited course with inadequate preclinical facilities, no clinical facilities, and only one continuing member of staff at the start of 2008. Having just typed this yesterday morning at 5 30, and now reread it, I think you must have been insane!

Just six months later, the preclinical laboratories are about treble in size, the plans for the Mildura clinic are out to tender, the schematic plans for the Wodonga clinic are drawn and Melton is girding its loins. Detailed proposals have been made for the additional facilities required. There is now a Professor and Head of School with 17 years of teaching experience, the first Associate Professor in Oral Health in Australia, who has 15 years of teaching experience, and a jet setting Senior Lecturer fresh to the red brick towers. More will come to make their own contribution to create the most radical dental program in the Southern hemisphere.

When Tony Blair advised the Houses of Parliament that he was stepping down as Prime Minister, he simply said "The End".

What I can say to you now, is that this is "the beginning". Thank you.